The Medical Record as a Source Document

CHAPTER OVERVIEW
 The medical record is the source document for coding.
 Medical records contain a variety of reports. These include the
following:

-- Reason the patient came to the hospital

-- Tests performed and their findings

-- Therapies provided

-- Descriptions of surgical procedures

-- Daily records of patient progress

 The discharge summary provides a synopsis of the patient's stay.

LEARNING OUTCOMES
 
After studying this chapter you should be able to:
 
Explain what is present in a medical record.
 
Understand when it is appropriate to query a physician about his or her documentation.

TERMS TO KNOW
 
POA indicator
present on admission indicator; a data element that applies to diagnosis codes for
claims involving inpatient care
 
Provider
a physician or any qualified health care practitioner (such as a nurse practitioner or
physician assistant) who is legally accountable for establishing the patient's diagnosis

REMEMBER
 
Coding professionals must make sure that the medical record documentation supports
the principal diagnosis.
. . . Refer to appendix B of this handbook for more information on the POA indicator.

INTRODUCTION
 
The source document for coding and reporting diagnoses and procedures is the
medical record. Although discharge diagnoses are usually recorded on the face sheet,
a final progress note, or the discharge summary, further review of the medical record
is needed to ensure complete and accurate coding. Operations and procedures are
frequently not listed on the face sheet or are not described in sufficient detail, making
a review of operative reports, pathology reports, and other special reports imperative.
The entire record should be reviewed to determine the specific reason for the
encounter and the conditions treated.
     In some institutions, midlevel providers, such as nurse practitioners and physician
assistants, are involved in the care of the patient and can document diagnoses in the
medical record. It is appropriate to base code assignments on the documentation of
midlevel providers if they are considered legally accountable for establishing a
diagnosis within the regulations governing the provider and the facility. The ICD-10-
CM Official Guidelines for Coding and Reporting use the term "provider" to mean
physician or any qualified health care practitioner who is legally accountable for
establishing the patient's diagnosis. The term "provider" in the remaining text of this
chapter is used in the same way.
     Providers sometimes fail to list reportable conditions that developed during the
stay but were resolved prior to discharge. Conditions such as urinary tract infection or
dehydration, for example, are often not included in the diagnostic statement even
though progress notes, providers' orders, and laboratory reports make it clear that such
conditions were treated. It is inappropriate to assign a diagnosis based solely on a
provider's orders for prescribed medications without the provider's documentation of
the diagnosis being treated. If enough information is present to strongly suggest that
an additional diagnosis should be reported, the provider should be consulted; no
diagnosis should be added without the approval of the provider. Because diagnostic
statements sometimes include diagnoses that represent past history or existing
diagnoses that do not meet the Uniform Hospital Discharge Data Set (UHDDS)
guidelines for reportable diagnoses, a review of the medical record is required to
determine whether these diagnoses should be coded for this encounter.
     It is customary to list the principal diagnosis first in the diagnostic statement.
Many providers, however, are not aware of coding and reporting guidelines, and,
consequently, this custom is not consistently followed. Because the correct
designation of the principal diagnosis is of critical importance in reporting diagnostic
information, make sure that medical record documentation supports the designation of
principal diagnosis. If it appears that another diagnosis should be designated as the
principal diagnosis, or if it seems that conditions not listed should be reported, follow
the health care facility's procedures for obtaining a corrected diagnostic statement.

CONTENTS OF THE MEDICAL RECORD

 
Medical records contain a variety of reports that document the reason the patient came
to the hospital, the tests performed and their findings, the therapies provided,
descriptions of any surgical procedures, and daily records of the patient's progress.
Each report contains important information needed for accurate coding and reporting
of the principal diagnosis, other diagnoses, and the procedures performed.
     A number of standard reports can be found in almost any medical record, but other
reports will appear depending on the condition for which the patient is being treated,
the extent of workup and therapy provided, and the provider's style of documentation.
For example, a provider may list final diagnoses on the admission record (face sheet),
on progress notes, or on the discharge summary. Consultants occasionally record their
consultation notes in the progress notes rather than on separate reports.
     Review of the inpatient medical record should begin with the discharge summary,
when available, because it provides a synopsis of the patient's hospital stay, including
the reason for admission, significant diagnostic findings, the treatment given, the
patient's course in the hospital, the follow-up plan, and the final diagnostic statement.
 The history section usually indicates the reason for admission (principal diagnosis),
which may require confirmation by review of the history and physical examination
and admitting and emergency department records.
     The section of the discharge summary that describes the patient's course in the
hospital usually indicates treatment that has been given and any further workup that
has been done. This section is particularly useful in determining whether all listed
diagnoses meet the criteria for reporting and identifying other conditions that may
merit reporting.
     Conditions mentioned elsewhere in the body of the discharge summary do not
necessarily warrant reporting but may provide clues for more specific review to make
a final determination. The medical record should be reviewed further to determine
whether such conditions meet the criteria for reportable diagnoses as defined in the
UHDDS. The medication record is often helpful in indicating that therapeutic
treatment may have been administered, but do not assume a diagnosis solely on the
basis of medication administration or abnormal findings in diagnostic reports. In
addition, recorded diagnoses do not always contain sufficient information for
providing the required specificity in coding. For example, a diagnosis of pneumonia
may not indicate the organism responsible for the infection; a review of diagnostic
studies of the sputum may provide this information. The provider should be asked to
confirm that the organism discovered on the positive culture is the causative agent.
Then the provider should indicate his or her confirmation by documenting it in the
medical record; this step must be taken before a code identifying the specific type of
pneumonia can be assigned. A diagnosis of fracture may indicate which bone was
fractured but not the particular part of the bone, information that is necessary for
accurate code assignment. The X-ray or the operative report should supply these data.
It is appropriate to utilize imaging reports to provide greater specificity of the
anatomical site as documented by the provider; for example, an X-ray report to
identify the location of a fracture, or an imaging report, such as a magnetic resonance
imaging (MRI) study, to determine the location of the stroke or infarction in a patient
diagnosed with a cerebral infarction or hemorrhagic stroke.
     Some facilities may develop their own additional coding guidelines to provide
assistance in determining when a provider query is appropriate. If the test findings are
outside the normal range and the provider has ordered other tests to evaluate the
condition or prescribed treatment, it is appropriate to ask the provider whether the
diagnosis should be added. However, a facility's internal guidelines may not interpret
abnormal findings to replace provider documentation or a provider query.
     The following examples illustrate diagnoses that are often recorded with less-than-
complete information but can be coded more specifically by referring to diagnostic
reports within the medical record and then obtaining the appropriate provider
confirmation. Note the variation in code assignment when more information is
available after provider confirmation:
 
  • Diagnosis: C53.9 Cancer of cervix
    Pathology report: D06.9 Carcinoma, in situ, of cervix
         
  • Diagnosis: N39.0 Urinary tract infection
    Laboratory report: N39.0 + B96.20 E. coli in urine
         
  • Diagnosis: S72.90xA Fracture of femur, initial encounter
    X-ray report: S72.21xB Open fracture of subtrochanteric neck of the
right femur, initial encounter
 
     Diagnosing a patient's condition is solely the responsibility of the provider. Code
assignment is generally based on the provider's documentation, not on clinical criteria
used by the provider to establish the diagnosis. Coding professionals should not
disregard provider documentation and decide on their own-based on clinical criteria,
abnormal test results, and so forth-whether or not a condition should be coded. The
provider's diagnostic statement that a patient has a particular condition is sufficient for
coding assignment.
     It is also appropriate to base code assignment on the documentation of other
physicians (e.g., consultants, residents, anesthesiologists) involved in the care and
treatment of the patient so long as there is no conflicting information from the
attending physician. A physician query is not necessary if a physician involved in the
care and treatment of the patient, including any of the consulting physicians, has
documented a diagnosis and there is no conflicting documentation from another
physician. If documentation from different physicians conflicts, the attending
physician should be queried for clarification because he or she is ultimately
responsible for the final diagnosis.
     For inpatient coding, if the provider does not confirm the pathological or
radiological findings, query him or her regarding the clinical significance of the
findings and request that appropriate documentation be provided. Although the
pathologist or radiologist provides a written interpretation of a tissue biopsy or an X-
ray image, this is not equivalent to the attending physician's medical diagnosis, which
is based on the patient's complete clinical picture. The attending physician is
responsible for, and directly involved in, the care and treatment of the patient. For
example, if the attending physician documented "breast mass" and the pathologist
documented "carcinoma of the breast," this would be conflicting information
requiring clarification from the attending physician.
     When coding outpatient laboratory, pathology, and radiology encounters in
hospital-based as well as stand-alone facilities, it is appropriate to assign codes on the
basis of the written interpretation by a radiologist or pathologist.
     Not all reportable services or procedures during an encounter or admission are
performed or documented by physicians. It is appropriate to assign a procedure code
based on documentation by the nonphysician professional who provided the service.
This applies only to procedure coding where there is documentation to substantiate
the code. It does not apply to diagnosis coding. The documentation from the
nonphysician professional who provided the service may be the only evidence that the
service was provided. This is true of services such as infusions carried out by nurses
and therapies provided by physical, respiratory, or occupational therapists.
     Outpatient records generally contain less information than inpatient records do;
nevertheless, all available reports for the encounter should be reviewed prior to code
assignment. Code assignment depends on the information available at the time of
code assignment. Documentation for the current encounter should clearly reflect those
diagnoses that are current and relevant for that encounter. Conditions documented on
previous encounters may not be clinically relevant for the current encounter. When
reporting a recurring condition, and the condition is still valid for the outpatient
encounter or inpatient admission, the recurring condition should be documented in the
medical record with each encounter/admission. However, if the condition is not
documented in the current medical record, it would be inappropriate to go back to
previous encounters to retrieve a diagnosis without physician confirmation.
     For ambulatory records, an additional data element called "patient's reason for
visit" (PRV) is usually reported. The PRV is reported on unscheduled outpatient visits
(e.g., emergency department or urgent care visits) to identify the main reason the
patient sought treatment. The reason may differ from the physician's final diagnosis at
the end of the encounter. If there are multiple conditions present, the code most likely
to justify the patient encounter should be reported. This data element is found at Form
Locator 70a-c on the UB-04 paper claim. Both the UB-04 paper claim and the
electronic claim allow the reporting of three diagnosis codes for the patient's reason
for visit.
     The "present on admission" (POA) indicator is a data element approved by the
National Uniform Billing Committee for inpatient reporting. The POA indicator
applies to the diagnosis codes for claims involving inpatient admissions to general
acute care hospitals or other facilities. Please refer to appendix B of this handbook for
more detailed information on this topic.